RN Transition Coach — Care Coordination & Safe Discharges

Molina Healthcare; Naperville (IL); On-site; USD 38,000 - 74,000; Full time

Job summary

Molina Healthcare in Naperville, IL is seeking a Registered Nurse to lead care transition activities, coordinating hospital discharge planning and post-discharge follow-up to reduce readmissions. You will work across hospitals, providers, and family support networks, ensuring safe, timely, and cost-effective care for members across settings.

The role requires CTI knowledge, strong communication, independence, and proficient use of Microsoft Office.

Qualifications

• RN with active license in state of practice.
• 2+ years healthcare experience including discharge planning, care management, or behavioral health.
• Valid driver's license and reliable transportation for travel requirements.

Responsibilities

• Follows member through a 30-day program from hospital admission through transitions to other settings to reduce readmissions.
• Collaborates with discharge planners, hospitalists, providers, facility staff and family/support network to ensure safe transitions.
• Ensures transitions have adequate caregiving, supervision, medical and medication oversight.
• Works with other service providers to arrange services and equipment for safe transitions.
• Conducts face-to-face hospital visits and home visits for high-risk members after discharge as needed.
• Coordinates care and reassesses needs using the Coleman Care Transition model post-discharge.
• Educates members on medication management, health records use, follow-up care and other Transition of Care pillars.
• Uses motivational interviewing and Molina clinical guideposts to support and motivate change.
• Identifies barriers to care and provides care coordination assistance.
• Facilitates ICT meetings and collaboration with interdisciplinary teams.

Skills

Care coordination

Discharge planning

Communication (verbal & written)

Time management

Independence/self-motivation

Microsoft Office

CTI knowledge

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare in Naperville, IL is seeking a Registered Nurse to lead care transition activities, coordinating hospital discharge planning and post-discharge follow-up to reduce readmissions. You will work across hospitals, providers, and family support networks, ensuring safe, timely, and cost-effective care for members across settings.

The role requires CTI knowledge, strong communication, independence, and proficient use of Microsoft Office.